Cookeville Regional Medical Center

A Modern Makeover

The hospital’s new main lobby artfully boasts soothing earth tones, plenty of natural light, and intimate areas for patients and visitors to rest.-Photo by Bob Schatz

We firmly believe standardization is a way to prevent medical errors.

With patient populations coming from 13 counties, Cookeville Regional Medical Center’s aging facility was quickly outgrowing its ability to serve patients efficiently. GS&P was tasked with integrating five decades of architectural styles and implementing design and process improvements that would enhance the patient care experience. With the project’s guiding principles as a beacon and without a traditional space program, design decisions were led by process, efficiency, access to natural light, and definitive distinctions between public and private spaces.

This has been a multifaceted project that started several years ago. How long have you been working on this portion?

Jeffery Morris: We’ve been working with CRMC since 1998. This portion started in 2004. It was in design for about two years and three years of construction.

Going in, did you realize it was going to be so complex?

Rob Hamby: Decisions regarding the location of the addition and the floor-to-floor heights were made in earlier master planning exercises. The owner elected to tie the addition to the existing building at an intersection of two previous additions, each with a different structural system, and to match the existing floor heights of 13 feet which would limit space for mechanical systems and ceiling heights. We knew from the beginning that working within these constraints would be difficult. To adapt, we selected a concrete structure which is unusual for a hospital structure of this size.

What is the normal structural material and why use concrete?

Jeff: The norm is steel because of its ease of construction, and it’s much more flexible, but the depth of the floor structure is usually more than with concrete.

Describe the overall hospital environment before GS&P started the project.

Jeff: It was a rural hospital built over five decades starting in the 1950s with semiprivate rooms. It wasn’t very inviting for patients, family, or visitors. It also had multiple entrances, which caused confusion for anyone entering the building.

Rob: The interior environment was unwelcoming and, in certain places, uncomfortable. Many spaces were limited in the amount of attention paid to patient or visitor, which didn’t match the new experience they wanted to create.

What kind of environment did they want to create?

Rob: First, the hospital was looking for a new identity and a new front entrance. The facility had patients and visitors entering through many different entrances, and once inside, it was difficult to tell where to go. So they wanted an easily identifiable front door and clear wayfinding. Their other overall request was for the new addition to feel “comfortable.”

The hospital is a very large structure that serves 13 counties. How do you make such a large facility comfortable?

Jeff: There’s a real focus on not only the patient experience but the family experience, with various respite areas to sit or wait that are smaller and cozy. It’s not the typical waiting room where you have 14 different families and kids running around. You have smaller areas with three or four seats, and there are tables on the patient floors so that if the family wants to eat, they can go right outside the room.

Erin Carnes: The concept has to do with stimulating all of the senses to help involve the patients and visitors. One example is locating different sub-waiting areas specifically throughout the patient floor.

How did you incorporate nature into the environment?

Rob: Simple things like focusing on natural light. Each patient room has a large expanse of glass. Every nurses’ station also has direct access to natural light and a view. The building is surrounded with landscaping and gardens, provided for patients’ use.

Jeff: We situated the addition to allow the majority of rooms to have a view to the surrounding landscape, which is typically hard to do. It created an unusual floor plate, but the new patient rooms are not looking at an old part of the hospital or into adjacent patient rooms.

Since you had to work with the existing building, how did you blend the new with the old without being too obvious?

Rob: Materials were a big part of that. We were actually lucky enough to find the same brick used in the 1970s and 1980s so it is a perfect match. We had a lot of discussions with the owner and knew that they wanted something that “fit” the campus but was a big improvement in the quality of design. By using similar and complementary materials, a similar scale, and building on the vertical elements of the existing building, we created a contemporary addition that does not look out of place with the rest of the campus.

Erin: It’s difficult to create a seamless transition between the existing and new construction because they are so drastically different from an interior finish standpoint. That was really a challenge. Color was very important. Nothing was themed or stylistic. Reiterating the idea of bringing nature inside, we used a lot of natural materials, earth tones, wood laminates, and contrasting colors throughout to unify everything. Even the elevator lobbies are all consistent, showing vertical circulation. We tried to keep the permanent elements, like the casework, pretty timeless so they can repaint easily to freshen up.

What are some of the immediate effects of the new environment?

Jeff: One of the hospital’s guiding principles was that they wanted their nurses to travel 60 feet or less between the nurses’ station, patient rooms, and all support areas they used every day. We were able to design the floor plate in such a way to stick to that, which is probably less than half of what most nurses travel in the course of their day. So, the floor was designed around the nurses’ needs and how they wanted to deliver care to their patients.
Another guiding principle was to embrace family support. All the patient rooms are private and are a third larger than typical patient rooms, with flat-screen TVs and pull-out sleeper sofas to accommodate several family members. Wayfinding was improved so patients and visitors now know where they are and where they’re going — a huge plus from a patient and family satisfaction standpoint.

Rob: The owners were very receptive to new ideas, but they had to change some of their internal processes to accommodate many of them. For instance, not only did they commit to providing additional space for family members, but they also extended visiting hours to make the patients more accessible to the families. In addition, the ICU now has similar open access visiting hours. In the past, ICU visitors had to be buzzed in through a secure door.

What other atypical changes did you propose?

Jeff: We created a new patient intake area that functions similar to a restaurant. You always come in through the front door whether it’s for preadmission testing, registration, surgery, or to visit family members. So the front door creates the identity they wanted from the beginning as part of the original guiding principles. Room and floor standardization was also a very different concept. Med Surg floors were designed with core functions identical on each floor. Our rationale was that nurses should always be familiar with their surroundings. We firmly believe standardization is a way to prevent medical errors.

Rob: And we did it without a formal space program. Typically, when we begin a project, the client has a very specific set of requirements regarding quantities and sizes of spaces that is followed with no questions asked. This facility was designed with an end dollar amount in mind, but with no preconceived notions of program elements. Functional requirements and staff work flow led all decisions about spaces to be included in the building.

Jeff: Theoretically, this is the way we ought to be designing hospitals versus “Here’s your program. Now go put the puzzle together.” As a design firm, we were able to stretch the boundaries of their thinking further than anyone thought possible, and I think that translated into being a building that should last and look good for 40 to 50 years. There are a lot of clients out there who are trying to build things as cheap as possible and it’s not getting the quality building that will last years and years like they are accustomed to having. So it costs them more in the long run.

This project has taken years to complete. What are the aspects for which you are most proud?

Jeff: I’m very proud of the fact that this is a project that we did fully through the GS&P design process, a documented process that started a couple of years ago with the guiding principles, MDSTs (multidiscipline study teams), and FMEA (failure modes and effects analysis). As a design firm, we were able to push these principles further than anyone imagined. We were able to consolidate five decades of architecture and actually turn it into a facility that functions as a whole unit. This project is a culmination of six to eight years of planning to get to this point. We were able to take all of the other projects that we had done and finally tie them all together so that they work the way we’d envisioned several years ago. That feels pretty good.

Erin: This was the first project I worked on when I joined GS&P. Being a very complicated project to start out with, the team did a great job of explaining the conceptual elements. This aided in being able to expedite and facilitate the client’s vision.

Rob: We were completely successful in meeting the hospital’s guiding principles for the project. After years of work, it is good to look back and see that the building is doing everything that we expected it to do regarding patient and staff comfort and the other guiding principles. The staff, volunteers, and the public have all been very positive about the new addition, and that is reflected in our continued relationship with the hospital.

Associated Builders and Contractors, Inc. North Alabama Chapter, 2008 Award of Excellence, Healthcare Projects Between $25 Million and $100 Million

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Gresham, Smith and Partners is a privately held firm of architects, engineers, interior designers and planners creating design and consulting solutions for the built environment. Our more than 800 employees are committed to building value with our clients as trusted advisors and to making positive social, economic and environmental impacts in our communities. In 2017, GS&P proudly celebrates 50 years in business. We look forward to continuing to serve our clients while fostering the professional and personal growth of our employees.